ITL, Inc.

EXEMPTION CERTIFICATE

FEDERAL/STATE EXCISE TAX ON DIESEL DYED DIESEL

Purchaser, ________________________________________________________, hereby certifies that:

All dyed diesel fuel ordered by the “Purchaser” for the period beginning on January 1, _____ and ending December 31, ______ (period not to exceed 12 calendar months) will be used for the following tax exempt purpose:

(Check applicable type of certificate)

_____ 1. Use as a fuel on a farm for farming purpose.

_____ 2. Exclusive use by state or local government.

_____ 3. Off-road business

If this dyed diesel fuel is resold or used for a purpose other than as stated in this certificate, then purchaser may be subject to tax.

Purchaser will be prepared to establish satisfactory evidence the purpose for which purchaser uses the product bought under this certification.

Purchaser understands that any fraudulent use of this certification to buy dyed diesel fuel for on road use may subject purchaser to penalties of perjury, which may include fine and/or imprisonment.

Print Name & Title

Signature

Purchaser

Address

FEIN or Social Security No

City, State  & Zip

Date

Telephone No.:

TO BE EXEMPT ALL FIELDS MUST BE COMPLETELY FILLED OUT

RETURN COMPLETED FOR BY FAX TO (323) 560-1170